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Precancers and Skin Cancers Adam O. Goldstein, MD, MPH Associate Professor Family Medicine University of North Carolina at Chapel Hill

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Presentation on theme: "Precancers and Skin Cancers Adam O. Goldstein, MD, MPH Associate Professor Family Medicine University of North Carolina at Chapel Hill"— Presentation transcript:

1 Precancers and Skin Cancers Adam O. Goldstein, MD, MPH Associate Professor Family Medicine University of North Carolina at Chapel Hill

2 Actinic Keratoses premalignant skin lesions = keratinocytic intraepidermal neoplasia premalignant skin lesions = keratinocytic intraepidermal neoplasia chronic sun, radiation or polycyclic aromatic hydrocarbons chronic sun, radiation or polycyclic aromatic hydrocarbons Skin Type I-II Skin Type I-II organ transplant organ transplant

3 Actinic Keratosis

4 Actinic Keratoses Distribution: Sunexposed, esp. dorsa hands/forearms Distribution: Sunexposed, esp. dorsa hands/forearms Description: papules,plaques with scale and erythema, occasional crust or cutaneous horn Description: papules,plaques with scale and erythema, occasional crust or cutaneous horn Sandpapery feel Sandpapery feel

5 Actinic Keratoses epidermal atypia epidermal atypia abnormal maturation abnormal maturation

6 Actinic Keratoses 60% predisposed >40 have at least 1 AK 60% predisposed >40 have at least 1 AK 6-10% lifetime >> invasive SCC 6-10% lifetime >> invasive SCC >10 AK - 14% an SCC w/n 5 yrs >10 AK - 14% an SCC w/n 5 yrs 60-97% of SCC from AK 60-97% of SCC from AK ~ 40% of met SCC>> AK ~ 40% of met SCC>> AK ^ aggressive immsupp ^ aggressive immsupp

7 Actinic Keratoses lip lesions: actinic cheilitis/leukoplakia lip lesions: actinic cheilitis/leukoplakia white plaques-mucosa white plaques-mucosa persistent scaling lesions on the lip persistent scaling lesions on the lip ^ aggressive behavior ^ aggressive behavior tobacco/sun tobacco/sun

8 Differential Diagnosis squamous cell carcinoma: more indurated, thicker, recurrence of AK after treatment squamous cell carcinoma: more indurated, thicker, recurrence of AK after treatment

9 Differential Diagnosis seborrheic keratosis: hyperpigmented,more stuck on appearing seborrheic keratosis: hyperpigmented,more stuck on appearing

10 Differential Diagnosis nummular eczema: coin-shaped scaling lesions; responds to emollients/topical corticosteroids nummular eczema: coin-shaped scaling lesions; responds to emollients/topical corticosteroids

11 AK Treatment PREVENTION PREVENTION Screen for skin cancers Screen for skin cancers Broad-brimmed hats Broad-brimmed hats sun protective clothing sun protective clothing sunscreens sunscreens avoidance of sunlight avoidance of sunlight ed s/sx skin cancer ed s/sx skin cancer avoidance of tobacco avoidance of tobacco low fat diet? low fat diet?

12 AK Treatment C ryosurgery(liquid nitrogen) C ryosurgery(liquid nitrogen) 5-fluorouracil cream or solution 5-fluorouracil cream or solution Diclofenac Sodium-3% gel Diclofenac Sodium-3% gel Imiquimod 2 x week/ 16 weeks Imiquimod 2 x week/ 16 weeks

13 AK Treatment Excision Excision Electrocautery Electrocautery Curettage Curettage Carbon dioxide laser Carbon dioxide laser

14 AK Treatment Chemical peels Chemical peels Photodynamic therapy Photodynamic therapy Retinoids-topical/oral Retinoids-topical/oral Investigational-dimericine Investigational-dimericine

15 TREATMENT Liquid Nitrogen-Advantages Liquid Nitrogen-Advantages cure rates of 98.8% cure rates of 98.8% common common minimal patient ed minimal patient ed multiple/thicker lesions multiple/thicker lesions quick recovery quick recovery

16 TREATMENT Liquid Nitrogen-Disadvantages Liquid Nitrogen-Disadvantages storage storage pain pain pigment alteration pigment alteration training training

17 5-Fluorouracil Cure 50-80% Cure 50-80% Blocks methylation reaction of deoxyuridylic acid to thymidilic acid Blocks methylation reaction of deoxyuridylic acid to thymidilic acid DNA (and RNA) synthesis DNA (and RNA) synthesis

18 Diclonfenac Sodium 3% Topical Gel mechanism of action unknown mechanism of action unknown NSAID NSAID inhibition of cyclo- oxygenase >>>PGE- 2 inhibition of cyclo- oxygenase >>>PGE days BID--overall % clearance vs % vehicle 90 days BID--overall % clearance vs % vehicle avoid ASA triad avoid ASA triad hypersensitivity hypersensitivity

19 Photodynamic therapy (Pariser DM - J Am Acad Dermatol -2003)

20 Cycle therapy of actinic keratoses of the face and scalp with 5% topical imiquimod cream: An open-label trial. Cycle therapy of actinic keratoses of the face and scalp with 5% topical imiquimod cream: An open-label trial. Salasche SJ et al Am Acad Dermatol 2002;47: Significant irritation Rest periods required Evolving protocols Expensive Effective

21 Skin Cancer Statistics >1 million cases/yr >1 million cases/yr >50% of all new cancers >50% of all new cancers 1 in 5 Americans will develop skin cancer 1 in 5 Americans will develop skin cancer

22 Types of Skin Cancers Basal Cell Carcinoma - 80% Basal Cell Carcinoma - 80% Squamous Cell Carcinoma - 16% Squamous Cell Carcinoma - 16% Melanoma - 4% Melanoma - 4%

23 BCC /SCC Most common skin cancers Most common skin cancers Most important risk factors Most important risk factors sun exposure sun exposure family history family history skin type skin type Incidence of these cancers increase with age, probably related to cumulative sun exposure Incidence of these cancers increase with age, probably related to cumulative sun exposure

24 Basal Cell Carcinoma the most common skin cancer the most common skin cancer 90% appear on face, ears, head 90% appear on face, ears, head

25 Main Types Basal Cell Carcinomas Nodular BCCs - most common type Nodular BCCs - most common type Sclerosing BCCs (morpheaform) Sclerosing BCCs (morpheaform) Superficial BCCs Superficial BCCs

26 Pattern of Nodular BCC raised pearly white, smooth translucent surface with telangiectasias raised pearly white, smooth translucent surface with telangiectasias

27 Pattern of Nodular BCCs may ulcerate leaving a small bloody crust may ulcerate leaving a small bloody crust may be pigmented may be pigmented

28 Pattern of Sclerosing BCCs ivory or colorless ivory or colorless flat or atrophic flat or atrophic indurated indurated may resemble scars may resemble scars are easily overlooked are easily overlooked

29 Pattern of Sclerosing BCCs ivory or colorless ivory or colorless flat or atrophic flat or atrophic indurated indurated may resemble scars may resemble scars are easily overlooked are easily overlooked

30 Pattern of Superficial BCCs and SCC in situ red or pink scaling plaques red or pink scaling plaques occasionally with shallow erosions or crusts occasionally with shallow erosions or crusts differentiation between these two similar lesions usually requires a biopsy differentiation between these two similar lesions usually requires a biopsy

31 Pigmented BCCs may look like melanoma may look like melanoma increased brown or black pigment increased brown or black pigment seen more commonly in dark-skinned individuals seen more commonly in dark-skinned individuals

32 Differential Diagnosis of Nodular BCC Intradermal nevus Intradermal nevus Sebaceous hyperplasia Sebaceous hyperplasia Fibrous papule of the face Fibrous papule of the face trichoepithelioma trichoepithelioma

33 Differentiating Intradermal Nevus from Nodular BCC Intradermal nevus Intradermal nevus Stable size Stable size Soft Soft No crusting or ulceration No crusting or ulceration May have telangiectasias May have telangiectasias

34 Differentiating Intradermal Nevus from Nodular BCC Intradermal nevus Intradermal nevus Stable size Stable size Soft Soft No crusting or ulceration No crusting or ulceration May have telangiectasias May have telangiectasias

35 Sebaceous Hyperplasia from Nodular BCC Sebaceous hyperplasia Sebaceous hyperplasia yellow coloration yellow coloration stable size stable size umbilication without ulceration umbilication without ulceration is hard to see after injecting anesthesia is hard to see after injecting anesthesia

36 Diagnosis of Basal Cell Carcinomas Shave biopsy Shave biopsy nodular nodular thick superficial types thick superficial types Punch biopsy Punch biopsy morpheaform morpheaform flat superficial types flat superficial types

37 Treatment options for Basal Cell Carcinomas C + D after a shave biopsy C + D after a shave biopsy Cryotherapy with thermocouple if you have experience Cryotherapy with thermocouple if you have experience Excision with 3- 5 mm margins Excision with 3- 5 mm margins Superficial trunk/ext: imiquimod qd x 12 wks Superficial trunk/ext: imiquimod qd x 12 wks Mohs for recurrent BCC and areas of cosmetic importance Mohs for recurrent BCC and areas of cosmetic importance

38 Mohs micrographic surgery removal of tumor by scalpel in sequential horizontal layers. removal of tumor by scalpel in sequential horizontal layers. each tissue sample is frozen, stained, and microscopically examined each tissue sample is frozen, stained, and microscopically examined repeated until all the margins are clear repeated until all the margins are clear treatment of choice for BCCs with poorly defined margins treatment of choice for BCCs with poorly defined margins especially those on the nose or eyelids especially those on the nose or eyelids

39 Recurrence rates after Tx of BCCs C + D 10% C + D 10% Cryotherapy 10% Cryotherapy 10% Excision 2 - 5% Excision 2 - 5% Imiquimod ??? Imiquimod ??? Mohs <1% Mohs <1%

40 Factors that increase recurrence rates sclerosing vs others sclerosing vs others larger size of BCC larger size of BCC margins margins experience of the surgeon experience of the surgeon

41 Sclerosing BCC is most dangerous tend to be deeply invasive tend to be deeply invasive often not diagnosed until they have caused extensive damage often not diagnosed until they have caused extensive damage invade muscle, nerve, and bone invade muscle, nerve, and bone nodular BCC can also invade deeply nodular BCC can also invade deeply

42 Bowens disease - features SCC in situ SCC in situ Mainly sun exposed areas Mainly sun exposed areas Slightly elevated red scaly plaque with well-demarcated borders Slightly elevated red scaly plaque with well-demarcated borders

43 Bowens disease - features May resemble psoriasis, superficial BCC, chronic eczema, SK May resemble psoriasis, superficial BCC, chronic eczema, SK Curable using C & D, cryo, 5-FU, imiquimod, excision Curable using C & D, cryo, 5-FU, imiquimod, excision

44 Keratoacanthoma Appear suddenly, grow rapidly Appear suddenly, grow rapidly Central crater with keratin plug Central crater with keratin plug May grow to 2cm in size May grow to 2cm in size May resolve spontaneously May resolve spontaneously May look like SCC May look like SCC

45 Keratoacanthoma C and D C and D elliptical excision elliptical excision 5-FU topically tid 5-FU topically tid 5-FU intralesional injection 5-FU intralesional injection

46 Location of SCCs Same distribution as bccs. Same distribution as bccs. Especially on the lips, ears, and scalp Especially on the lips, ears, and scalp Initially grow by direct extension Initially grow by direct extension Metastasize to local lymph nodes and then to distant sites Metastasize to local lymph nodes and then to distant sites

47 SCCs with an increased risk of metastasis larger, advanced lesions larger, advanced lesions SCC on mucous membranes (in the oral cavity, on the lips) SCC on mucous membranes (in the oral cavity, on the lips) BCCs rarely metastasize BCCs rarely metastasize

48 SCC more aggressive (local & mets) Size >2 cm Size >2 cm SCC in a scar SCC in a scar Patient is immunosuppressed Patient is immunosuppressed Poorly differentiated Poorly differentiated There is perineural invasion There is perineural invasion

49 Importance of early diagnosis of BCC and SCC especially in facial cancers especially in facial cancers the nose is the single most frequent site of BCC the nose is the single most frequent site of BCC reconstruction is difficult reconstruction is difficult extension into underlying bone and cartilage may occur extension into underlying bone and cartilage may occur

50 The differential diagnosis of superficial BCC and SCC in situ Actinic keratosis, nummular eczema Actinic keratosis, nummular eczema Nummular eczema can usually be distinguished by its coin-like shape, transient nature, and itchiness Nummular eczema can usually be distinguished by its coin-like shape, transient nature, and itchiness Biopsy any thickened and crusting actinic keratosis to rule out BCC or SCC Biopsy any thickened and crusting actinic keratosis to rule out BCC or SCC

51 Treatment options for SCC C + D after a shave biopsy C + D after a shave biopsy cryotherapy with thermocouple if you have experience cryotherapy with thermocouple if you have experience excision with 5 mm margin excision with 5 mm margin Mohs for recurrent SCC and areas of cosmetic importance Mohs for recurrent SCC and areas of cosmetic importance

52 Erythroplasia of Queyrat SCC in situ on the penis SCC in situ on the penis Usually under the foreskin of the uncircumcised penis Usually under the foreskin of the uncircumcised penis May occur on the vulva May occur on the vulva 5-FU, imiquimod or mohs 5-FU, imiquimod or mohs

53 Indications for Referral for Mohs Surgery

54 Recurrent tumors, sclerosing BCC Recurrent tumors, sclerosing BCC Primary tumors in locations with high tumor- recurrence rates Primary tumors in locations with high tumor- recurrence rates Nasolabial fold,temple, periauricular area, periocular area, scalp, nasal alae, center face Nasolabial fold,temple, periauricular area, periocular area, scalp, nasal alae, center face Preservation of normal tissue is vital (for cosmetic and functional reasons) Preservation of normal tissue is vital (for cosmetic and functional reasons) Nose, eyelids, lips, fingers, ears, penis Nose, eyelids, lips, fingers, ears, penis

55 When to consider referral Aggressive and recurrent skin cancers Aggressive and recurrent skin cancers A large skin cancer lesion A large skin cancer lesion A lesion located in a sensitive area (cosmetic or functional) A lesion located in a sensitive area (cosmetic or functional) When treatment or diagnosis of the lesion is beyond the scope of ones skills When treatment or diagnosis of the lesion is beyond the scope of ones skills If mohs surgery is the treatment of choice If mohs surgery is the treatment of choice

56 Melanoma Risk Factors Family history Family history Personal history Personal history Atypical Nevi Atypical Nevi Blistering Sunburns Blistering Sunburns Type 1 skin Type 1 skin

57 History of a changing lesion

58 Melanoma Statistics Fastest rising incidence rates Fastest rising incidence rates Most common cancer in 25-9 y/o Most common cancer in 25-9 y/o 2nd only to breast CA in 30-4 y/o women 2nd only to breast CA in 30-4 y/o women

59 Melanoma Facts 87,900 new cancers 87,900 new cancers 34,300 in situ 34,300 in situ 53,600 invasive 53,600 invasive 4% increase from % increase from deaths in 2003 due to melanoma 7400 deaths in 2003 due to melanoma

60 Melanoma

61 Melanoma-Early detection Total treatment costs by stage Total treatment costs by stage Stage I 5.5% Stage I 5.5% Stage II 5.5% Stage II 5.5% Stage III 34% Stage III 34% Stage IV 55% Stage IV 55%

62 MNEMONIC FOR MALIGNANT MELANOMA RECOGNITION A- ASYMMETRY A- ASYMMETRY B- BORDER IRREGULARITY B- BORDER IRREGULARITY C- VARIATION IN COLOR C- VARIATION IN COLOR D- DIAMETER>.6CM D- DIAMETER>.6CM E- ELEVATION ABOVE SKIN SURFACE E- ELEVATION ABOVE SKIN SURFACE

63 Melanoma with regression

64 Melanoma

65 Acral lentiginous Melanoma

66 Lentigo Maligna Melanoma

67 Venous Lake

68 Blue Nevus

69 Seborrheic Keratosis

70 Pyogenic Granuloma

71 Look everywhere

72 Melanoma Management Excisional biopsy Excisional biopsy 1-2 mm margins 1-2 mm margins Dermatopathologist consultation Dermatopathologist consultation

73 Breslows Measurement Depth of granular cell layer to deepest malignant cell Depth of granular cell layer to deepest malignant cell Strongest correlation with prognosis Strongest correlation with prognosis

74 Melanoma Managment Sentinel lymph node biopsy Sentinel lymph node biopsy 1mm or greater depth, regression, >Level III or IV 1mm or greater depth, regression, >Level III or IV Interferon Interferon Vaccine clinical trials Vaccine clinical trials

75 Melanoma Management Full skin exam Full skin exam Family screening Family screening Follow up Follow up Education Education

76 Take home points Prevent skin cancers by risk factor reduction Prevent skin cancers by risk factor reduction Early detection of pre-cancers and skin cancers can prevent morbidity and mortality Early detection of pre-cancers and skin cancers can prevent morbidity and mortality Use the appropriate biopsy technique for diagnosing skin cancers Use the appropriate biopsy technique for diagnosing skin cancers Treat or refer based on your skills Treat or refer based on your skills

77 Online References Derm Online Atlas is at Derm Online Atlas is at Derm Image Bank is at medstat.med.utah.edu/kw/derm/ Derm Image Bank is at medstat.med.utah.edu/kw/derm/ Basal Cell Carcinoma is at emedicine.com/derm/topic47.htm Basal Cell Carcinoma is at emedicine.com/derm/topic47.htm


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